Frenotomy and Human Factors Science
In 2019, a woman in New South Wales, across the border from me, took her seven-week-old baby in for a frenotomy. Shortly afterwards, in a heartbreaking Instagram post, she said that her baby was being ventilated. A blood vessel had been cut during the frenotomy, the little child was rushed by ambulance to an Emergency Department for resuscitation, and they were now on their way to an intensive care unit.
My heart went out to that baby and to the family. How terrible, how terrifying! But my thoughts also turned to the dentist who performed that frenotomy because he will be, surely, in a state of great distress. A health professional’s life can be defined by an event like this.
Mistakes are inevitable in medical or dental practice. This is why the new ‘human factors science’ addresses health system problems in order to both minimise error, and prepare for it.(1)
The Instagram post was forwarded to me by health professionals who had already been worrying a lot about the frenotomy industry. They’d been worrying about the oral aversion they were regularly seeing in babies afterwards, about the risk of infection and haemorrhage and damage to the lingual nerves, responsible for sensation of the front part of the tongue.(2) They’d been worrying because there was a 420% increase in Medicare-rebated frenotomies in 0-4 year-olds between 2006-2016 and our Australian study couldn’t track frenotomies by dentists, who may be performing the majority.(3) This pattern is characteristic of serious overtreatment, and mirrors overseas studies.(4-6)
Finally, they’d been worrying because when there is an exponential increase in the number of times a surgical procedure is performed, the risk of mishap rises dramatically. Since this baby nearly died across the border from me, another case report has been published of delayed haemorrhage and shock in a six-week-old Canadian baby, five days after a laser frenotomy.(7)
Though there is the occasional classic tongue-tie that requires a scissors frenotomy, many babies are referred for oral surgery under the upper lip and tongue for common breastfeeding problems and related unsettled behaviour. The Canadian baby had been referred because of shallow latch, pain with breastfeeding, fussiness, possets after feeds, and open mouth rest posture. Surgical intervention is justified by outdated biomechanical models of infant suck, or by methodologically weak (that is, biased) research which providers claim as ‘proof’ of the benefits.(8) Australia’s most well-known breastfeeding education organisations continue to showcase studies or audits which contain serious methodological flaws (that is, bias) as proof of the benefits of frenotomy in the absence of classic tongue-tie.
The international frenotomy industry is lucrative, and powerful, and exercises control over dissenting practitioners’ income through social media lists of ‘tongue-tie friendly’ or ‘tongue-tie competent’ professionals, alongside condemnation of breastfeeding-ignorant professionals who ‘miss’ the tongue or upper lip-tie. Because of the lack of regulation across international borders, someone like myself who has spoken out about the anatomically inaccurate and clinically unhelpful diagnosis of ‘posterior tongue-tie’ or the anatomically inaccurate belief that ‘behind every classic tongue-tie there is a posterior tongue-tie’ or the pathologizing of normal labia frenula as ‘upper lip-ties’ can be defamed by overseas personalities who have huge followings, without consequence.(9-11)
In 2019, any organisation I’ve belonged to for many years, Lactation Consultants of Australia and New Zealand, agreed to circulate a paid advertisement of our Masterclasses offering education in a new approach to breastfeeding support which does not require oral surgery for babies (unless there is a classic tongue-tie) - and then two days later sent an email of retraction to all members, instructing them to delete it, falsely claiming our Masterclasses violated the WHO International Code of Marketing Breastmilk Substitutes! When a highly respected academic and leader like Professor Laurence Walsh AO, who first taught Australian dentists to use laser technologies, raised concerns about tongue-tie and fringe science on SBS’s ‘The Feed’, the practice manager and husband of a dentist who appeared on that same program wrote on a tongue-tie professionals’ Facebook page that ‘perhaps in his advancing years [Professor Walsh] is losing the plot.’
Such extraordinary behaviour towards dissenting colleagues remains widespread amongst breastfeeding support professionals who refer regularly for frenotomies, and amongst those who identify as tongue-tie professionals. The income and status of those who specialise in identifying infant oral restrictions or providing infant frenotomy depends on persuading the public that health professionals who question surgical intervention cannot be trusted.
Parents dealing with the distress of breastfeeding problems and related unsettled infant behaviour typically do not need to take their babies to dentists or others who perform frenotomy. But unfortunately they often need help beyond what is offered by their breastfeeding support professionals. The research demonstrates that current approaches to latch and positioning are often ineffective,(12-14) and may even sometimes, paradoxically, cause nipple damage.(15) Clinical breastfeeding support remains a research frontier, rarely prioritised, for historical reasons, by funding bodies.
But it did seem to me when I first began to publish about the inappropriateness of oral surgery for breastfeeding babies in the absence of classic tongue-tie, that I also had a moral responsibility to do my very best to bring to breastfeeding women effective therapeutic alternatives. Now, our Neuroprotective Developmental Care offers a gestalt approach to breastfeeding developed from clinical experience and a new biomechanical model of infant suck and swallow derived from ultrasound, vacuum, and MRI studies.(16-18) Day by day, in the clinic over many years now, I have watched breastfeeding relationships transform with careful fit and hold work based on the gestalt biomechanical model and a neuroprotective developmental care approach to complex, breastfeeding-related problems, without surgery and without pharmaceuticals.
If we want to minimise the chance of human factor error causing harm to our breastfeeding babies then we, as breastfeeding support professionals and advocates, need to get serious about understanding how to interpret evidence and identify bias. We need to treat dissenting colleagues with respect and listen to their point of view – we need to invite them in, rather than attack them or close ranks and exclude them! We need funding bodies to invest in innovation and high calibre research concerning clinical breastfeeding support. This is how we will minimise unnecessary surgery in our baby’s sensitive little mouths, and reduce human factor error.
Updated 24 January 2021
1. Russ AL, Fairbanks RJ, Karsh B-T, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Quality and Safety. 2013;22(802-808).
2. Hale M, Mills N, Edmonds L, Dawes P, Dickson N, Barker D, et al. Complications following frenotomy for ankyloglossia: a 24-month prospective New Zealand Paediatric Surveillance Unit study. Journal of Paediatrics and Child Health. 2019:doi:10.1111/jpc.14682.
3. Kapoor V, Douglas PS, Hill PS, Walsh L, Tennant M. Frenotomy for tongue-tie in Australian children (2006-2016): an increasing problem. MJA. 2018:88-89.
4. Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and lingual frenotomy: national trends in inpatient diagnosis and management in the United States, 1997-2012. Otolaryngology Head and Neck Surgery. 2017;156(4):735-740.
5. Joseph KS, Kinniburg B, Metcalfe A, Raza N, Sabr Y, Lisonkova S. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open. 2016;4:e33-e40.
6. Ellehauge E, Jensen JS, Gonhoj C, Hjuler T. Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark. Danish Medical Journal. 2020;67(5):A01200051.
7. Kim DH, Dickie A, Shih ACH, Graham ME. Delayed hemorrhage following laser frenotomy leading to hypovolemic shock. Breastfeeding Medicine. 2020:doi:10.1089/bfm.2020.0319.
8. Douglas PS. Making sense of studies which claim benefits of frenotomy in the absence of classic tongue-tie Journal of Human Lactation. 2017;33(3):519–523.
9. Douglas PS, Cameron A, Cichero J, Geddes DT, Hill PS, Kapoor V, et al. Australian Collaboration for Infant Oral Research (ACIOR) Position Statement 1: Upper lip-tie, buccal ties, and the role of frenotomy in infants Australasian Dental Practice. 2018;Jan/Feb 144-146.
10. Mills N, Pranksky S, Geddes DT, Mirjalili SA. What is a tongue tie? Defining the anatomy of the in-situ lingual frenulum. Clinical Anatomy. 2019:doi:10.1002/ca.23343.
11. Douglas PS. Re-thinking 'posterior' tongue-tie. Breastfeeding Medicine. 2013;8(6):1-4.
12. Schafer R, Watson Genna C. Physiologic breastfeeding: a contemporary approach to breastfeeding initiation. Journal of Midwifery and Women's Health. 2015;60:546-553.
13. Wood N, K, Woods NF, Blackburn ST, Sanders EA. Interventions that enhance breastfeeding initiation, duration and exclusivity: a systematic review. MCN. 2016;41(5):299-307.
14. Svensson KE, Velandia M, Matthiesen A-ST, Welles-Nystrom BL, Widstrom A-ME. Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial. International Breastfeeding Journal. 2013;8:1.
15. Thompson RE, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth. 2016;29:336-344.
16. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.
17. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509–518.
18. Mills N, Lydon A-M, Davies-Payne D, Keesing M, Mirjalili SA, Geddes DT. Imaging the breastfeeding swallow: pilot study utilizing real-time MRI. Laryngoscope Investigative Otolaryngology. 2020;5:572-579.
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